Psychedelics: Potent Partners in Palliative Care

Psychedelics have gained mainstream attention because of media’s reporting on promising research and Michael Pollan’s recent documentary on Netflix, How to Change Your Mind. The promise to reduce symptoms related to mental illness, and an ever-growing list of other conditions, such as neurodegenerative diseases, anorexia, cluster headaches, autism, substance use disorders, and more, is too good for people to ignore.

Many of the studies show promising results, with none more compelling than those using psilocybin with adjunct psychotherapy to reduce psychological and existential distress in those with life-threatening illnesses. For two decades, prestigious universities such as Johns Hopkins, NYU and UCLA have consistently shown that the use of psilocybin-assisted therapy reduces anxiety and depression in participants with advanced-stage cancer. Not only that, but participants also confronted their fear of dying, found meaning in their lives and felt at peace with their death and dying.
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The JHU researchers found that six months after two psilocybin dosing sessions with associated psychotherapy, 79% and 83% of participants significantly reduced depression and anxiety, respectively, and >80% reported increased feelings of well-being. Similarly, in a study conducted at the New York University Langone Medical Center, research showed that eight months following a single psilocybin dose, 83% and 58% of the participants were in remission for depression and anxiety, respectively.  

From these studies and others, participants commonly report a feeling of oneness and a reduction in the fear of dying, the latter considered a correlate for increased anxiety and depression in palliative care patients. JHU published a study August 24, 2022, to compare people who have used psychedelics to people who have experienced near death or similar experiences (NDEs). They surveyed 3,192 participants, 933 of them were non-psychedelics users but had NDEs, the remaining participants had used a variety of psychedelics, including psilocybin and LSD. One similarity between the groups found that 88% of the non-psychedelic users and 89% of the psychedelic users, experienced a reduction in their fear of dying. In general, they also found that the scores on the mystical and near-death experience questionnaires, were significantly higher in the Psychedelic Group than those in the Non-Psychedelic Group.

This leaves those of us wanting to ease the suffering for those at end-of-life in a tremendous quandary. Currently, the only legal recourse to the use of psilocybin is to travel out of country to places such as, the Netherlands, Jamaica or Costa Rica. One psilocybin retreat in Jamaica is the first to offer a specially curated psilocybin exploration with facilitated discussions on the topics of death and dying, as well as experiential training for hospice and palliative care professionals (full disclosure, I am on contract with them). The retreat, developed by an end-of-life doula and led by a psychedelic-trained psychotherapist with 30 years’ experience as a hospice social worker, help attendees and their families explore what a good death means to them.

Beyond that, we can wait until Oregon’s licensed Psilocybin Service Centers become fully operational, sometime in 2023. Or, if you live in Canada with a life-threatening illness and fortunate enough to be accepted into Canada Health’s Special Access Program, you may be prescribed psilocybin.

There is a less glamorous “psychedelic” that is gaining traction for palliative care. Ketamine is technically not even a psychedelic, it’s a dissociative anesthetic. It can be prescribed off-label in many countries including the US, Canada and the UK and shown great promise reducing severe chronic pain and symptoms of anxiety and depression. Although many health care professionals have administered it to patients in the context of emergency care or surgical procedures, it is not yet standard protocol in most palliative care centers where it arguably would be extraordinarily efficacious.

Ketamine has its pros and cons: although rapid acting, reducing severe chronic pain, anxiety and depression, as well as suicidal ideation, it is, relative to other psychedelics, shorter lasting. Board Certified Anesthesiologist, Dr. Steven Reichbach and founder of the Reichbach Center for Ketamine and Cannabis in Sarasota, Florida, administers Ketamine Intravenous Infusions according to the industry’s “gold standard” to extend its efficacy. He administers a series of six infusions over a 2-3 week period of time, followed by “boosters” on an as needed basis. This has the benefit of extending the duration of the therapeutic benefit, both for his chronic pain and mental health patients. The good news, too, is that many patients are referred to him by the local hospice agency with similar outcomes, reducing, not just anxiety, depression and suicidal ideation, but also easing his patients’ fear of dying.

Dr. Michelle Weiner, DO, MPH, is a Pain Management Specialist at Spine Wellness of America in the Miami, Florida area and frequent speaker on the topics of ketamine and psychedelics for palliative care. Her standard protocol is to administer a series of Ketamine Intramuscular Injections (IM) over a period of 3 - 6 weeks, then also offering boosters on an as needed basis. For some patients, she also prescribes lower dose ketamine sublingual lozenges (also called troches) for at-home use. This can effectively maintain a therapeutic benefit, reducing the number of in-clinic injections needed. With the proper preparation, setting and assistance at home some cancer patients may use a 100mg-200mg lozenge to help treat pain and end-of-life distress.

There is an excellent guide published March 2022 by Brain Futures on Psychedelic Medicine detailing the research on multiple psychedelics, including Ketamine. They report on several studies involving palliative care since “studies suggest that those suffering from chronic pain are four times more likely to have depression or anxiety than those who are pain-free.” By reducing chronic pain, the general consensus is that ketamine can greatly mediate anxiety and depression without the potential for opioid abuse. One of the studies Brain Futures reported on showed ketamine’s ability to reduce severe pain experienced by complex regional pain syndrome (CRPS) sufferers. The researchers showed that 76% of patients reported complete pain relief with 54% remaining pain free for more than 3 months.

And, supportive of Ketamine’s ability to reduce chronic pain effectively, one 2021 study found “use of a standardized Ketamine Step Protocol showed a statistically significant reduction in pain and Morphine Equivalent Daily Dose (MEDD) in patients with predominantly neuropathic cancer pain. It also demonstrated a safe and effective method for opioid reduction after commencement of parenteral ketamine.”

Ketamine’s future may even get brighter for palliative care. Yale University received a grant to study ketamine to relieve depression in patients with Parkinson’s and PharmaTher has FDA approval for a Phase II Clinical Trial to study the effects of Ketamine to reduce Levodopa-induced dyskinesia. Stay tuned to both psilocybin and ketamine as clinical trials and real-world studies continue to be compiled.

Christine Caldwell is the former owner of a 250-client home health agency, certified Neuro-Linguistics Programming life coach and Deepak Chopra Meditation and Health Instructor. She is currently enrolled in Psychedelics Today Psychedelics Integration Training Program and is on contract as Manager, End-of-Life Programs, for Diaspora Psychedelic Society, a psilocybin retreat in Jamaica. She also is a self-proclaimed neuroscience and quantum mechanics geek.
 
REFERENCES
1https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367557/
2https://journals.sagepub.com/doi/10.1177/0269881116675512
3https://journals.plos.org/plosone/article/file?type=printable&id=10.1371/journal.pone.0271926 
4https://www.brainfutures.org/mental-health-treatment/patevidence/
5https://pubmed.ncbi.nlm.nih.gov/15367304/
6https://www.tandfonline.com/doi/abs/10.1080/09699260.2021.1922146
7https://medicine.yale.edu/news-article/michael-j-fox-foundation-grant-will-fund-first-clinical-trial-of-ketamine-to-treat-depression-in-people-with-parkinsons-disease/
8https://clinicaltrials.gov/ct2/show/NCT04912115?term=ketamine&cond=Parkinson+Disease&draw=2&rank=2

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